Physician-Directed Interventions Can Help With Depression, Anxiety, Suicidality

By Will Boggs MD

NEW YORK—Physician-directed interventions are moderately effective for reducing symptoms of depression, anxiety and suicidality, according to a systematic review and meta-analysis.

Compared with the general population and other professional groups, physicians have a higher prevalence of depression, anxiety and suicidal ideation. On average, one physician a day dies by suicide in the U.S.

For their analysis, online February 7 in The Lancet Psychiatry, Dr. Samuel B. Harvey of the University of New South Wales, in Randwick, Australia, and colleagues found eight studies with data on a total of 1,023 physicians.

All of the studies involved physician-directed interventions, mostly including individual or group cognitive behavioral therapy (CBT) or mindfulness training. The researchers' search did not identify any controlled trials of organizational-level interventions.

Three studies showed a significant reduction in symptoms of depression (standardized mean difference, 0.53); four studies showed a significant reduction in general psychological distress (SMD, 0.65); one study showed a significant reduction in anxiety (SMD, 0.71); and one study showed a significant reduction in suicidal ideation during an internship year (risk ratio, 0.40), compared with control groups.

The pooled mean effect size was nominally greater for group-based interventions (SMD, 0.78) than in the single individual-based study (SMD, 0.39); effect sizes were similar for studies with a non-active control group (SMD, 0.62) and a study with an active control group (SMD, 0.74).

CBT or mindfulness-based interventions had nonsignificantly higher effect sizes (SMD, 0.79), compared with other approaches (SMD, 0.46).

"Given the prevalence of mental health morbidity among physicians, these findings should both guide the type of physician-focused interventions that are adopted among this group and serve as a call to action for the urgent need for more comprehensive rigorous research regarding individual and organizational interventions aimed at improving the mental health of physicians," the researchers conclude.

Dr. Ronald M. Epstein of the University of Rochester School of Medicine and Dentistry, in New York, who co-authored a linked editorial related to this report, told Reuters Health by email, "We need to move beyond just thinking about burnout to address the full spectrum of transient and enduring physician distress. Even the stress of a single medical catastrophe in an otherwise well-functioning physician can have consequences. Medical culture - typically stoical, individualistic, perfectionistic, and punitive - needs to change. Strong and enlightened leadership can make an important difference."

"The relative neglect of the problem is troubling, especially given that health care professionals have our lives in their hands and their mental well-being is essential to good, safe, humane, compassionate care," he said. "I have personally known seven physicians who died by suicide, many precipitated by stressors at work. They often were not functioning well prior to their suicides. And suicide is only the tip of the iceberg. I am disheartened at the trivialization of the problem and lack of funding for research to develop interventions."

"Health care institutions, health care educational programs, and the general public (should) insist on proactive and comprehensive programs to address the mental health of physicians and other health professionals," Dr. Epstein said. "This needs to be more than window-dressing. Real-time resources, thought, and wisdom need to go into the development of a culture of medicine that promotes openness about human vulnerabilities and collective resolve to address them. Otherwise, the public will be endangered and will not receive the quality of interpersonal and technical care that they deserve."

Dr. Jodie Eckleberry-Hunt is a health psychologist from Fenton, Michigan, who has researched various aspects of physician wellness, including burnout, depression, and suicide. She told Reuters Health by email, "I don't know that it is surprising, yet it is sad, how few published quality interventional studies exist for treatment of physician distress, especially given the overwhelming evidence that it is a problem. It is a dilemma that physicians feel so inundated with work that there is no time/energy left to participate in such studies, and organizationally, I don't yet see meaningful investment in changing this dynamic."

"First, I see a moral obligation to care for those who serve at the front lines of patient suffering and pain," she said. "The secondary trauma they experience, in addition to all of the other frustrations, is able to be ameliorated. We just need to make it a priority and find the best delivery model. Second, at the end of the line is the patient, and this is a public health issue. It is not just a physician problem. Extreme physician distress does have an impact on patient care, outcomes, and mishaps."

"So much more work needs to be done," said Dr. Eckleberry-Hunt, who was not involved in the new study. "This is where efforts should now be focused instead of just describing the problem. The problem is clear. It is what do we do with it. I think we need to think out of the box, and it is essential that organizations do more than give lip service support."

Dr. Harvey did not respond to a request for comments.

SOURCE: https://bit.ly/2XaYrlA and https://bit.ly/2twZ9vN

Lancet Psychiatry 2019.

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